Apporach to Hepatomegaly in internal medicine.pdf

hepatomegaly causes and approach

1. Hepatomegaly

2. CAUSES History Physical examination Investigation Treatments
o Hepatitis
o Infections
o Viral hepatitis
(acute and
chronic)
o EBV and
CMV
o Malaria
o Abscesses –
Amoebic or
Pyogenic
o Autoimmune hepatitis
o Alcoholic liver disease
o Non-alcoholic fatty liver
disease (previously known as
NASH)
o Tumours
o Metastases
o Hepatocellular
carcinoma (HCC)
o Hepatoma
o Haematological Disorders
o Leukaemia (CML and
CLL)
o Lymphoma
o Presenting complaint
– very varied and
depends on cause
o Abdominal
distension
o Nausea
o Pruritus
o Weight loss
o Pyrexia
o Pale stool/dark urine
o Change in bowel
habit
o Past medical history
o Autoimmune disease
o Inflammatory bowel
disease
o Medications
o Statins
o Amiodarone
o Antibiotic use
o Family history
o Malignancy
o Chronic liver disease
o Sickle cell disease
o Autoimmune disease
GENERAL EXAMINATION
• Generalized Oedema &
Abdominal
Distention –
Background CLCD
• Cachexia – Malignancy
(Liver secondaries)
• Stigmata of CLCD –
Parotid swelling,
Gynaecomastia, Body
hair loss, Spider navei,
Palmar erythema,
Dupuytren’s
contracture, White
nails.
Background CLCD &
Hepatomegaly favors
the diagnosis of
Hepatocellular
Carcinoma.
• Jaundice (Sclera,
Palms) – Malignancy
(Liver secondaries),
CLCD
o Blood tests:
o Full blood
count
o Urea and
electrolytes
o Liver
function tests
o Clotting
o Inflammatory
markers
o Blood film
o Full liver
screen (see
chronic liver
disease
section)
o Ultrasound abdomen

Further investigations
and management of
hepatomegaly
o Depends on cause
(see other
hepatology
=Treat
underlying
cause

3. o Haemolytic anaemias
o Thalassaemia;
red cell
defects; sickle
cell anaemia
o Infiltration
o Amyloidosis
o Sarcoidosis
o Drugs
o Statins
o Amiodarone
o Macrolides
o Metabolic
o Haemochromatosis
o Wilson’s disease
o Glycogen storage
disorders
o Porphyria
o Biliary Disease
o Extra-hepatic
obstruction
o Pancreatic
cancer;
cholangiocarci
noma
o Primary Biliary
Cirrhosis
o Primary Sclerosing
Cholangitis
o Congestive
o Right ventricular
failure
o Social history
o Travel history
o Alcohol
consumption
o Tattoos; blood
transfusions; risky
sexual behaviour

• Pallor (Conjunctiva,
Tongue) –
Hematological
malignancy, CLCD
• Finger Clubbing – GI
Lymphoma, CLCD4
• Asterixis – Hepatic
encephalopathy
• Ankle Oedema
• Lymphadenopathy –
Cervical, Axillary,
Epitrochlear
(Malignancy)
ABDOMINAL EXAMINATION
INSPECTION
• Abdominal
Distention (Ascites
seen in malignancy &
portal hypertension)
• Right hypochondrial
Fullness – (Large
hepatomegaly)
• Surgical
Scars (Peritoneal
aspiration marks, Liver
biopsy marks)
• Sister-Mary-Joseph
Nodule – Metastatic
deposits from bowel
gastroenterology
pages)

4. o Congestive cardiac
failure
o Constrictive
pericarditis
o Budd-Chiari

CA, hepatocellular
CA, and lymphoma
PALPATION
• Superficial Palpation –
Routine
• Organomegaly
(Hepatomegaly)
1. Palpate for
the lower
margin &
estimate the
size
2. Feel
the tenderness,
nodularity,
regularity and
consistency
3. Percuss for the
lower margin
from below
upwards
4. Percuss for
upper margin
from above
downwards
5. Exclude
coexisting
Splenomegaly
PERCUSSION
• Percuss for the liver

5. • Percuss for free fluid
AUSCULTATION
• Look for Hepatic bruit
(Hepatocellular CA,
Hepatic metastasis,
Alcoholic hepatitis)
EXTENDED EXAMINATION
Sometimes hepatomegaly may
be due to venous congestion
secondary to right heart
failure. Look for,
• Elevated JVP
• Loud second heart
sound
• Third heart Sound